Guidelines & References
ESPEN expert group recommendations for action against cancer-related malnutrition |
ESPEN practical guide: Clinical nutrition in cancer |
Clinical Oncology Society of Australia. Position statement: Cancer-related malnutrition and sarcopenia |
Grading
Uses tumour biopsy |
X to 4 |
Higher grade = undifferentiated = more intense treatment |
Staging
TNM. Higher number = more severe |
T = tumour size |
N = number of lymph nodes which contain cancer |
M = Distant metastasised |
T4N3M1 = large tumour which has spread significantly to lympth nodes and has metastasised – will continue to grow & spread rapidly |
Terminology
Benign (nonmalignant) = not cancer |
Malignant = cancer |
Metastasis = spread of cancer cells |
Neoadjuvant: Treatment given as a first step to shrink a tumour before the main treatment (usually surgery). Includes chemo, radiation or hormone therapy |
Adjuvant: Additional treatment given after the primary treatment to lower the risk of the cancer coming back. Includes chemo, radiation, hormones, biological or targeted therapy |
Cancer cachexia: unintentional weight and muscle loss in people with cancer, not fully reversible by eating more |
Types of cancers
Carcinomas |
Most common. Arise from epithelia cells. Breast, prostate, lung, colorectal, melanoma. |
Lymphoma |
Cancer of the lymphatic system (hodgkin lymphoma and non- Hodgkin lymphoma) |
Leukemia |
Cancer of white blood cells, often starting in bone marrow |
Multiple myeloma |
A cancer of plasma cells in the bone marrow. |
Sarcomas |
From bone, muscle, fat. Osteosarcoma (bone), Leiomyosarcoma (smooth muscle tissue) |
Glioblastoma |
An aggressive brain tumor. |
Types of cancers
Carcinomas |
Most common. Arise from epithelia cells. Breast, prostate, lung, colorectal, melanoma. |
Lymphoma |
Cancer of the lymphatic system (hodgkin lymphoma and non- Hodgkin lymphoma) |
Leukemia |
Cancer of white blood cells, often starting in bone marrow |
Multiple myeloma |
A cancer of plasma cells in the bone marrow. |
Sarcomas |
From bone, muscle, fat. Osteosarcoma (bone), Leiomyosarcoma (smooth muscle tissue) |
Glioblastoma |
An aggressive brain tumor. |
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Treatment
Chemo |
Oral, IV or injection |
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Given in cycles – gives the healthy cells a chance to grow back. C3D8 = cycle 3 (of 8), Day 8 (of the 14 day cycle) |
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S/E: V&D, constipation, dysphagia, fatigue, altered taste, oral thrush, thickened saliva, reflux, dry mouth, mucositis |
Immunotherapy |
Helps the patients own immune system to fight cancer Eg. immune checkpoint inhibitors or monoclonal antibodies |
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Not as big effect on nutrition |
Radiation (XRT) |
Kills or slows the growth of cells by damaging the DNA. In a big machine, similar to a CT scan. Measured in “grey” and given in “fractions” |
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S/S occur after 2 weeks of treatment & accumulate |
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S/E: Fatigue, dysphagia, diarrhea, vomiting, thick salvia, pain, taste changes, damage to bowels (eg bleeding) |
Intervention
Malnutrition assessment: SGA, PG-SGA SF (for chemo) |
Malnutrition screening – MST, MUST |
Sarcopenia screening (SARC-F) |
HPHE - ONS/Fortification/EN |
Educate: Food safety & hygiene – Immunocompromised. Avoid illness |
Depending on the person/prognosis: low-inflammatory foods – more so in people In remission |
Consider: site of cancer, refeeding risk, tube position (is it in the right place?) |
Nut Reqs
Energy ~125kJ |
Chemo & Radiation: >125kJ/kg |
Cancer cachexia: >125kJ/kg |
Malnutrition = repletion (125-145kJ) |
Protein ~1.2-1.5g |
Chemo & Radiation: >1.2g/kg |
Older/chronically ill/repletion: 1.2-1.5g/day |
Renal failure: 1.0-1.2g/kg |
Cancer cachexia: > 1.4g/kg |
Example PESS
Inadequate oral intake related to loss of appetite and nausea 2 to chemotherapy, as evidenced by pt consuming ~__% of EER and ___% of EPR* |
Food and nutrition knowledge deficit |
Inadequate protein-energy intake |
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Nutrition Strategies – based on S/S
CTCAE Grading 1 to 5. 1 = mild, intervention not indicated. 5 = death related to S/S. |
Taste Changes |
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↓ taste: add salt or seasoning, ginger, pickles, honey, adding herbs/spices, pickles, marinades, sauces etc |
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↑ taste: use straw. No added sugar products. Low salt alternatives. Avoid fizzy drinks/mints/chewing gum |
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Too salty: Roast meats over deli meats. Add sugar or honey to food. |
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Too sweet: Avoid added sugars/fruit etc. Plain breakfast cereals. Add salt or lemon juice. |
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Metallic: ginger, small sips of flavoured drinks. Non-metallic cutlery. Suck on boiled lollies |
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Feel like “sand”, “straw” “cardboard” – Change the consistency of the food, soft, moist foods, add sauces/gravies, soups & smoothies, drink lots of water, medications to replace saliva |
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pink lady – Gaviscon + a numbing agent – pharmacist |
Smell changes |
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Ask friends/family to cook for you |
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Cook in bulk and freeze |
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Bland foods. |
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Cold or room temp (avoid hot) |
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Avoid strong flavours: garlic, onion etc |
Anorexia |
Loss of appetite or desire to eat = ↓ food intake |
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Educate on malnutrition & importance in treatment |
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Using smaller plates |
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More frequent small meals |
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EN/ONS |
N/V |
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Medications – pharmacist |
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Cold food – usually better tolerated. sandwiches, salads, jelly, custard and yoghurt (NEMO) |
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Smaller frequent meals – avoid having an empty stomach Peppermint or ginger |
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Salty snacks/dry crackers, biscuits, noodles, cereal, toast, pretzels, crackers |
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Avoid alcohol and high volumes of coffee |
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sucking on ice blocks |
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regular small sips of water or cold clear fluids – cordial, lemonade, ginger ale, juice |
Mucositis & pain when swallowing |
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Artificial sweeteners |
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Sugar free gum |
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Avoiding hot food |
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Avoiding sources of trauma – hard toothbrush, crispy foods |
Diarrhoea |
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Medical management – consult medical team/Pharmacist |
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Monitor dehydration & electrolyte losses |
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Consider non-treatment causes – Fibre, lactose, intolerances, sugar-free products |
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Adequate hydration – electrolyte solutions |
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Limiting fatty/greasy dishes, high fibre foods and fizzy drinks |
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Bland foods |
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Avoid caffein |
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Try low lactose alternatives |
Loss of appetite |
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Meds: Appetite stimulants |
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Early satiety: prokinetics (stimulates GI movement) – consider constipation |
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HPHE & ONS – Sustagen, up & go, milkshakes etc |
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6 smaller meals/day |
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Encourage to eat by the clock – avoid waiting until they are hungry |
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Eat when appetite is better – commonly morning |
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Encourage favourite foods – discuss with family |
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Social eating |
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Softer foods that don’t require chewing |
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Cook in bulk and freeze – less exposure to food smells |
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Have ready-prepared meals/snacks |
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Encourage gentle exercise |
Oral Health |
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Regular sips of water to keep mouth hydrated & stimulates saliva |
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Gum, sucking on lollies |
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Sodium bicarb mouth wash |
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